J Cancer 2019; 10(5):1263-1274. doi:10.7150/jca.32386

Research Paper

Development and Validation of Nomograms Predictive of Axillary Nodal Status to Guide Surgical Decision-Making in Early-Stage Breast Cancer

Jiao Li1†, Weimei Ma1†, Xinhua Jiang1, Chunyan Cui1, Hongli Wang2, Jiewen Chen1, Runcong Nie1, Yaopan Wu1✉, Li Li1✉

1. Department of Medical Imaging, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangzhou, People's Republic of China
2. Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
† Equal contributors


Purpose: To develop and validate nomogram models using noninvasive imaging parameters with related clinical variables to predict the extent of axillary nodal involvement and stratify treatment options based on the essential cut-offs for axillary surgery according to the ACOSOG Z0011 criteria.

Materials and Methods: From May 2007 to December 2017, 1799 patients who underwent preoperative breast and axillary magnetic resonance imaging (MRI) were retrospectively studied. Patients with data on axillary ultrasonography (AUS) were enrolled. The MRI images were interpreted according to Breast Imaging Reporting and Data system (BI-RADS). Using logistic regression analyses, nomograms were developed to visualize the associations between the predictors and each lymph node (LN) status endpoint. Predictive performance was assessed based on the area under the receiver operating characteristic curve (AUC). Bootstrap resampling was performed for internal validation. Goodness-of-fit of the models was evaluated using the Hosmer-Lemeshow test.

Results: Of 397 early breast cancer patients, 200 (50.4%) had disease-free axilla, 119 (30.0%) had 1 or 2 positive LNs, and 78 (19.6%) had ≥3 positive LNs. Patient age, MRI features (mass margin, LN margin, presence/absence of LN hilum, and LN symmetry/asymmetry), and AUS descriptors (presence of cortical thickening or hilum) were identified as predictors of nodal disease. Nomograms with these predictors showed good calibration and discrimination; the AUC was 0.809 for negative axillary node (N0) vs. any LN metastasis, 0.749 for 1 or 2 involved nodes vs. N0, and 0.874 for ≥3 nodes vs. ≤2 metastatic nodes. The predictive ability of the 3 nomograms with additional pathological variables was significantly greater.

Conclusion: The nomograms could predict the extent of ALN metastasis and facilitate decision-making preoperatively.

Keywords: Breast cancer, Lymph node, Magnetic resonance imaging, Metastasis, Ultrasonography

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How to cite this article:
Li J, Ma W, Jiang X, Cui C, Wang H, Chen J, Nie R, Wu Y, Li L. Development and Validation of Nomograms Predictive of Axillary Nodal Status to Guide Surgical Decision-Making in Early-Stage Breast Cancer. J Cancer 2019; 10(5):1263-1274. doi:10.7150/jca.32386. Available from http://www.jcancer.org/v10p1263.htm